When the space between the collarbone and first rib gets tight, during movement or even at complete rest, it can lead to Thoracic Outlet Syndrome (TOS). Between the two structures mentioned above, we have the passage of the thoracic plexus (nerves) and blood vessels. The compression of those structure, can result in pain, weakness and numbness radiating down the shoulder, arm, and hand. Because TOS has multiple causes and presentations, effective treatment depends heavily on accurate assessment and an individualised approach, and that’s where myotherapy can play a crucial role.
What Causes Thoracic Outlet Syndrome?
As there are different tissues passing by this space, the nature of TOS can be broadly categorised into three types:
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Neurogenic TOS: Compression of the brachial plexus (nerves).
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Venous TOS: Compression of the subclavian vein.
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Arterial TOS: Compression of the subclavian artery.
But not only can different tissues be compressed, but different structures can be responsible for the compression.
Indeed, the compression can be due to the scalene muscle, pectoralis minor or bone.
And here are some common causes:
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Muscle imbalances that lead to poor posture (forward head/rounded shoulders);
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Repetitive overhead activities (which lead to constant compression of the tissues);
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Trauma (e.g. whiplash or clavicle fracture);
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Anatomical variations (such as a cervical rib).
The Role of Myotherapy in TOS Assessment
As a myotherapist, when treating someone with suspicious TOS, we go for a series of assessments that we compare to the clinical history and symptoms.
The test itself would aim to reproduce the patient’s symptoms and guide us on what potential structure is compressed. If we are suspicious of TOS, we can aim to reduce tension in soft tissue and give exercises that can reinforce those structures to alleviate any compression in the area.
Orthopedic Testing & Myotome Assessment
Some common assessments include:
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Adson’s Test (for scalene involvement) – It consists of reproducing a drop of heart bit in the wrist (affected side) by asking the patient to abduct and extend the arm while rotating (same side) and extending the neck. This would add extra compression on the suspected structures.
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Roos/Elevated Arm Stress Test (to reproduce vascular or neural symptoms) – It is about asking the patient to lift the arm at 90°/90° and start closing and opening their hands repetitively for 30 seconds to 1 minute. A drop of strength or symptom reproduction would lead to a positive test.
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Costoclavicular Maneuver (to assess space between clavicle and first rib) – It is delivered by having the patient with depressed and retracted shoulders. The positivity of this test is given by the reproduction of symptoms or a reduction in the distal wrist.
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Wright’s Hyperabduction Test (for pectoralis minor tightness) – The patients get asked to lift their arm (affected side) above their head while the therapist stands behind and keeps count of the wrist heartbeat. Any symptoms, reproduction, or drop in bit is considered positive.
In addition to those tests, we would use:
- Myotome testing: which assesses the motor function of specific spinal nerve roots;
- Clinical history: Any history of previous injury, surgeries, work and sport loads;
- Type and timing of symptoms: When and how those symptoms are reproduced on daily life.
All this said, we always have to consider that as therapists, myo or physio as per osteo exc… we can assume that the positivity of many of those test leads to a positive or negative conclusion regarding TOS.
Hands-on treatment and exercises in combination can be the easy steps to take to treat the presentation, but can not always guarantee the best outcome, due to each individual’s unique presentation.
Hands-On Treatment and Exercise Prescription
Once we have more understanding of what is potentially happening in terms of compression, a myotherapy treatment focuses on addressing the underlying causes:
Manual Therapy
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Myofascial release of the scalene, pectoralis minor, and upper trapezius muscles.
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Trigger point therapy to reduce local and referred pain patterns.
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Joint mobilisation to improve scapular movement and rib mechanics.
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Neural gliding techniques to encourage nerve mobility and reduce irritation.
Exercise Rehabilitation
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Postural re-education, particularly strengthening the deep neck flexors and lower trapezius.
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Scapular stabilisation exercises to improve shoulder mechanics.
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Breathing retraining is necessary if dysfunctional patterns (like apical breathing) are contributing to compression.
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Neurodynamic stretches are appropriate for nerve mobility.
Together, these interventions help reduce symptoms, improve function, and support long-term recovery.
The time frame for improvement, if not complete reduction of the symptoms, can be different per individual, but we can estimate a period of time that goes between 12 and 16 weeks. If no changes are reproduced within this time frame, that’s where we would refer the patient elsewhere for further investigations, like a scan.
When Is Surgery Needed for Thoracic Outlet Syndrome?
Surgical intervention is typically reserved for cases where conservative care fails or in cases of vascular TOS, where there’s a risk of thrombosis or embolism, but also where anatomical variations, like a cervical rib is present.
Surgical procedures may include:
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Scalenectomy (removal of the scalene muscles)
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First rib resection
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Clavicle decompression or repair if there’s previous trauma
These operations aim to create more space in the thoracic outlet, thus relieving the compression.
Post-Surgical Recovery and the Role of Myotherapy
In case of surgery, as a myotherapist, we can still help and ensure a correct recovery post-intervention. Treatment like MLD can help in flushing excess liquid out of the surgery area, but again, we would look into exercises as a form of recovery and rehabilitation of the area affected by the surgery and or affected by the lack of strength that is a consequence of a prolonged period of muscle weakness.
More broadly, myotherapy treatment can help with:
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Pain management
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Scar tissue
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Muscle guarding or weakness
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Neurological symptoms that may persist or reappear
Do You Need a Scan if we’re suspicious of TOS?
Imaging, as discussed in other blogs, may be recommended when we are suspicious of other presentations, or if standard method are not creating any difference. For example:
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To rule out cervical disc herniation, tumours, or other causes of neurovascular symptoms.
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When conservative treatment isn’t improving symptoms within a few months.
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Before surgical planning, particularly for vascular TOS, a Doppler ultrasound, MRI, or CT angiogram may be required.
Electrodiagnostic testing (EMG and nerve conduction studies) may also be useful for suspected neurogenic cases.
Final Thoughts
Thoracic Outlet Syndrome can be complex and frustrating, but with an informed and individualised approach, many people find relief without surgery. At Melbourne Massage and Treatment, via myotherapy treatment, I offer a comprehensive strategy, from differential diagnosis through orthopedic and neurological testing to targeted manual therapy and rehabilitation. And if surgery is necessary, I will be happy to pass on all the information and findings we assess to your GP or other practitioner, and still be able to assist you with post-surgery recovery and help restore function safely and effectively.
If you’re experiencing persistent neck, shoulder, or arm symptoms, reach out for a professional assessment. You will find me in Fitzroy North, and with a click, you can book your initial consultation or a 15-minute free online consultation.
FAQs – Thoracic Outlet Syndrome
A: Not exactly. While TOS can involve nerve compression (neurogenic TOS), it differs from a pinched nerve in the neck or spine. A pinched nerve typically occurs at the spinal level (like cervical radiculopathy), whereas TOS involves compression of the brachial plexus or blood vessels between the collarbone and first rib. Orthopedic and neurological assessments help differentiate the two.
A: Yes, poor posture — especially forward head position and rounded shoulders — can lead to muscle imbalances and chronic compression of the thoracic outlet. Over time, this can irritate nerves or restrict blood flow, leading to the symptoms associated with TOS. Corrective postural exercises are a key part of myotherapy treatment.
A: While each person responds differently, we generally look for symptom improvement over 12 to 16 weeks of consistent treatment and exercise. If there’s no notable change within that time, we may suggest further investigations or refer you for imaging to rule out other causes or confirm diagnosis.
A: Early signs often include intermittent numbness or tingling in the fingers, shoulder or neck tightness, or a feeling of heaviness or fatigue in the arm, especially after overhead activity. If left untreated, these can become more constant and painful. Early assessment makes a big difference.
A: Not always. In fact, most cases of TOS respond well to conservative care like myotherapy, postural correction, and exercise. Surgery is typically a last resort, considered only when symptoms are severe, persistent, or due to anatomical issues like a cervical rib.
A: Exercises that focus on postural strengthening, such as activating the lower trapezius, deep neck flexors, and scapular stabilisers, are often prescribed. Stretching tight structures (like scalene or pec minor), breathing retraining, and neurodynamic glides can also help reduce symptoms and restore function.
A: It can affect both. Athletes who perform repetitive overhead movements (like swimmers or weightlifters) and workers with poor ergonomics or repetitive tasks (like tradies or desk-based roles) are often at risk. The underlying cause may vary, but the treatment principle stays individualised.
A: Yes, myotherapy can be a key part of post-surgical recovery. From managing swelling through Manual Lymphatic Drainage (MLD), to improving scar mobility, reducing muscle guarding, and gradually rebuilding strength, we work closely with you to restore comfort and function after your procedure.
Giovanni La Rocca
Giovanni moved to Melbourne, Australia, from Italy in 2008 and became a citizen in 2017. He started studying massage therapy in 2016, then completed a Bachelor of Health Science in Clinical Myotherapy in August 2024. During those years, he also specialised in Thai Massage and Manual Lymphatic Drainage for presentations like Lipoedema and Lymphoedema. Nowadays, he runs his clinic in Fitzroy North, Melbourne, where he integrates movement therapy into his practice to enhance overall well-being. He also values meditation, having completed several Vipassana courses. Committed to continuous learning, he aims to share his expertise in integrated therapies to help others achieve balance and resilience.